|Other names||Diarrhoea (or diarrhœa)|
|An electron micrograph of rotavirus, the cause of nearly 40% of hospitalizations from diarrhea in children under five|
|Specialty||Infectious disease, gastroenterology|
|Symptoms||Loose frequent bowel movements, dehydration|
|Causes||Usually infection (viral, bacterial, parasitic)|
|Risk factors||Contaminated food or water|
|Prevention||Handwashing, rotavirus vaccination, breastfeeding|
|Treatment||Oral rehydration solution, zinc supplementation|
|Frequency||≈2.4 billion (2015)|
|Deaths||1.53 million (2019)|
Diarrhea, also spelled diarrhoea or diarrhœa, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin with loss of the normal stretchiness of the skin and irritable behaviour. This can progress to decreased urination, loss of skin color, a fast heart rate, and a decrease in responsiveness as it becomes more severe. Loose but non-watery stools in babies who are exclusively breastfed, however, are normal.
The most common cause is an infection of the intestines due to either a virus, bacterium, or parasite—a condition also known as gastroenteritis. These infections are often acquired from food or water that has been contaminated by feces, or directly from another person who is infected. The three types of diarrhea are: short duration watery diarrhea, short duration bloody diarrhea, and persistent diarrhea (lasting more than two weeks, which can be either watery or bloody). The short duration watery diarrhea may be due to cholera, although this is rare in the developed world. If blood is present, it is also known as dysentery. A number of non-infectious causes can result in diarrhea. These include lactose intolerance, irritable bowel syndrome, non-celiac gluten sensitivity, celiac disease, inflammatory bowel disease such as ulcerative colitis, hyperthyroidism, bile acid diarrhea, and a number of medications. In most cases, stool cultures to confirm the exact cause are not required.
Diarrhea can be prevented by improved sanitation, clean drinking water, and hand washing with soap. Breastfeeding for at least six months and vaccination against rotavirus is also recommended. Oral rehydration solution (ORS)—clean water with modest amounts of salts and sugar—is the treatment of choice. Zinc tablets are also recommended. These treatments have been estimated to have saved 50 million children in the past 25 years. When people have diarrhea it is recommended that they continue to eat healthy food and babies continue to be breastfed. If commercial ORS is not available, homemade solutions may be used. In those with severe dehydration, intravenous fluids may be required. Most cases, however, can be managed well with fluids by mouth. Antibiotics, while rarely used, may be recommended in a few cases such as those who have bloody diarrhea and a high fever, those with severe diarrhea following travelling, and those who grow specific bacteria or parasites in their stool. Loperamide may help decrease the number of bowel movements but is not recommended in those with severe disease.
About 1.7 to 5 billion cases of diarrhea occur per year. It is most common in developing countries, where young children get diarrhea on average three times a year. Total deaths from diarrhea are estimated at 1.53 million in 2019—down from 2.9 million in 1990. In 2012, it was the second most common cause of deaths in children younger than five (0.76 million or 11%). Frequent episodes of diarrhea are also a common cause of malnutrition and the most common cause in those younger than five years of age. Other long term problems that can result include stunted growth and poor intellectual development. File:En.Wikipedia-VideoWiki-Diarrhea.webm
Diarrhea is defined by the World Health Organization as having three or more loose or liquid stools per day, or as having more stools than is normal for that person.
Acute diarrhea is defined as an abnormally frequent discharge of semisolid or fluid fecal matter from the bowel, lasting less than 14 days, by World Gastroenterology Organization. Acute diarrhea that is watery may be known as AWD (Acute Watery Diarrhoea.)
Secretory diarrhea means that there is an increase in the active secretion, or there is an inhibition of absorption. There is little to no structural damage. The most common cause of this type of diarrhea is a cholera toxin that stimulates the secretion of anions, especially chloride ions (Cl–). Therefore, to maintain a charge balance in the gastrointestinal tract, sodium (Na+) is carried with it, along with water. In this type of diarrhea intestinal fluid secretion is isotonic with plasma even during fasting. It continues even when there is no oral food intake.
Osmotic diarrhea occurs when too much water is drawn into the bowels. If a person drinks solutions with excessive sugar or excessive salt, these can draw water from the body into the bowel and cause osmotic diarrhea. Osmotic diarrhea can also result from maldigestion, e.g. pancreatic disease or coeliac disease, in which the nutrients are left in the lumen to pull in water. Or it can be caused by osmotic laxatives (which work to alleviate constipation by drawing water into the bowels). In healthy individuals, too much magnesium or vitamin C or undigested lactose can produce osmotic diarrhea and distention of the bowel. A person who has lactose intolerance can have difficulty absorbing lactose after an extraordinarily high intake of dairy products. In persons who have fructose malabsorption, excess fructose intake can also cause diarrhea. High-fructose foods that also have a high glucose content are more absorbable and less likely to cause diarrhea. Sugar alcohols such as sorbitol (often found in sugar-free foods) are difficult for the body to absorb and, in large amounts, may lead to osmotic diarrhea. In most of these cases, osmotic diarrhea stops when the offending agent, e.g. milk or sorbitol, is stopped.
Exudative diarrhea occurs with the presence of blood and pus in the stool. This occurs with inflammatory bowel diseases, such as Crohn's disease or ulcerative colitis, and other severe infections such as E. coli or other forms of food poisoning.
Inflammatory diarrhea occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-rich fluids and a decreased ability to absorb these lost fluids. Features of all three of the other types of diarrhea can be found in this type of diarrhea. It can be caused by bacterial infections, viral infections, parasitic infections, or autoimmune problems such as inflammatory bowel diseases. It can also be caused by tuberculosis, colon cancer, and enteritis.
If there is blood visible in the stools, it is also known as dysentery. The blood is a trace of an invasion of bowel tissue. Dysentery is a symptom of, among others, Shigella, Entamoeba histolytica, and Salmonella.
Diarrheal disease may have a negative impact on both physical fitness and mental development. "Early childhood malnutrition resulting from any cause reduces physical fitness and work productivity in adults," and diarrhea is a primary cause of childhood malnutrition. Further, evidence suggests that diarrheal disease has significant impacts on mental development and health; it has been shown that, even when controlling for helminth infection and early breastfeeding, children who had experienced severe diarrhea had significantly lower scores on a series of tests of intelligence.
Diarrhea can cause electrolyte imbalances, kidney impairment, dehydration, and defective immune system responses. When oral drugs are administered, the efficiency of the drug is to produce a therapeutic effect and the lack of this effect may be due to the medication travelling too quickly through the digestive system, limiting the time that it can be absorbed. Clinicians try to treat the diarrheas by reducing the dosage of medication, changing the dosing schedule, discontinuation of the drug, and rehydration. The interventions to control the diarrhea are not often effective. Diarrhea can have a profound effect on the quality of life because fecal incontinence is one of the leading factors for placing older adults in long term care facilities (nursing homes).
In the latter stages of human digestion, ingested materials are inundated with water and digestive fluids such as gastric acid, bile, and digestive enzymes in order to break them down into their nutrient components, which are then absorbed into the bloodstream via the intestinal tract in the small intestine. Prior to defecation, the large intestine reabsorbs the water and other digestive solvents in the waste product in order to maintain proper hydration and overall equilibrium. Diarrhea occurs when the large intestine is prevented, for any number of reasons, from sufficiently absorbing the water or other digestive fluids from fecal matter, resulting in a liquid, or "loose", bowel movement.
Acute diarrhea is most commonly due to viral gastroenteritis with rotavirus, which accounts for 40% of cases in children under five. In travelers, however, bacterial infections predominate. Various toxins such as mushroom poisoning and drugs can also cause acute diarrhea.
Chronic diarrhea can be the part of the presentations of a number of chronic medical conditions affecting the intestine. Common causes include ulcerative colitis, Crohn's disease, microscopic colitis, celiac disease, irritable bowel syndrome, and bile acid malabsorption.
There are many causes of infectious diarrhea, which include viruses, bacteria and parasites. Infectious diarrhea is frequently referred to as gastroenteritis. Norovirus is the most common cause of viral diarrhea in adults, but rotavirus is the most common cause in children under five years old. Adenovirus types 40 and 41, and astroviruses cause a significant number of infections. Shiga-toxin producing Escherichia coli, such as E coli o157:h7, are the most common cause of infectious bloody diarrhea in the United States.
Campylobacter spp. are a common cause of bacterial diarrhea, but infections by Salmonella spp., Shigella spp. and some strains of Escherichia coli are also a frequent cause.
In the elderly, particularly those who have been treated with antibiotics for unrelated infections, a toxin produced by Clostridioides difficile often causes severe diarrhea.
Parasites, particularly protozoa e.g., Cryptosporidium spp., Giardia spp., Entamoeba histolytica, Blastocystis spp., Cyclospora cayetanensis, are frequently the cause of diarrhea that involves chronic infection. The broad-spectrum antiparasitic agent nitazoxanide has shown efficacy against many diarrhea-causing parasites.
Other infectious agents, such as parasites or bacterial toxins, may exacerbate symptoms. In sanitary living conditions where there is ample food and a supply of clean water, an otherwise healthy person usually recovers from viral infections in a few days. However, for ill or malnourished individuals, diarrhea can lead to severe dehydration and can become life-threatening.
Open defecation is a leading cause of infectious diarrhea leading to death.
Poverty is a good indicator of the rate of infectious diarrhea in a population. This association does not stem from poverty itself, but rather from the conditions under which impoverished people live. The absence of certain resources compromises the ability of the poor to defend themselves against infectious diarrhea. "Poverty is associated with poor housing, crowding, dirt floors, lack of access to clean water or to sanitary disposal of fecal waste (sanitation), cohabitation with domestic animals that may carry human pathogens, and a lack of refrigerated storage for food, all of which increase the frequency of diarrhea ... Poverty also restricts the ability to provide age-appropriate, nutritionally balanced diets or to modify diets when diarrhea develops so as to mitigate and repair nutrient losses. The impact is exacerbated by the lack of adequate, available, and affordable medical care."
One of the most common causes of infectious diarrhea is a lack of clean water. Often, improper fecal disposal leads to contamination of groundwater. This can lead to widespread infection among a population, especially in the absence of water filtration or purification. Human feces contains a variety of potentially harmful human pathogens.
Proper nutrition is important for health and functioning, including the prevention of infectious diarrhea. It is especially important to young children who do not have a fully developed immune system. Zinc deficiency, a condition often found in children in developing countries can, even in mild cases, have a significant impact on the development and proper functioning of the human immune system. Indeed, this relationship between zinc deficiency and reduced immune functioning corresponds with an increased severity of infectious diarrhea. Children who have lowered levels of zinc have a greater number of instances of diarrhea, severe diarrhea, and diarrhea associated with fever. Similarly, vitamin A deficiency can cause an increase in the severity of diarrheal episodes. However, there is some discrepancy when it comes to the impact of vitamin A deficiency on the rate of disease. While some argue that a relationship does not exist between the rate of disease and vitamin A status, Others suggest an increase in the rate associated with deficiency. Given that estimates suggest 127 million preschool children worldwide are vitamin A deficient, this population has the potential for increased risk of disease contraction.
Malabsorption is the inability to absorb food fully, mostly from disorders in the small bowel, but also due to maldigestion from diseases of the pancreas.
- enzyme deficiencies or mucosal abnormality, as in food allergy and food intolerance, e.g. celiac disease (gluten intolerance), lactose intolerance (intolerance to milk sugar, common in non-Europeans), and fructose malabsorption.
- pernicious anemia, or impaired bowel function due to the inability to absorb vitamin B12,
- loss of pancreatic secretions, which may be due to cystic fibrosis or pancreatitis,
- structural defects, like short bowel syndrome (surgically removed bowel) and radiation fibrosis, such as usually follows cancer treatment and other drugs, including agents used in chemotherapy; and
- certain drugs, like orlistat, which inhibits the absorption of fat.
Inflammatory bowel disease
The two overlapping types here are of unknown origin:
- Ulcerative colitis is marked by chronic bloody diarrhea and inflammation mostly affects the distal colon near the rectum.
- Crohn's disease typically affects fairly well demarcated segments of bowel in the colon and often affects the end of the small bowel.
Irritable bowel syndrome
Another possible cause of diarrhea is irritable bowel syndrome (IBS), which usually presents with abdominal discomfort relieved by defecation and unusual stool (diarrhea or constipation) for at least three days a week over the previous three months. Symptoms of diarrhea-predominant IBS can be managed through a combination of dietary changes, soluble fiber supplements and medications such as loperamide or codeine. About 30% of patients with diarrhea-predominant IBS have bile acid malabsorption diagnosed with an abnormal SeHCAT test.
Diarrhea can be caused by other diseases and conditions, namely:
- Chronic ethanol ingestion
- Certain medications
- Bile acid malabsorption
- Ischemic bowel disease: This usually affects older people and can be due to blocked arteries.
- Microscopic colitis, a type of inflammatory bowel disease where changes are seen only on histological examination of colonic biopsies.
- Bile salt malabsorption (primary bile acid diarrhea) where excessive bile acids in the colon produce a secretory diarrhea.
- Hormone-secreting tumors: some hormones, e.g. serotonin, can cause diarrhea if secreted in excess (usually from a tumor).
- Chronic mild diarrhea in infants and toddlers may occur with no obvious cause and with no other ill effects; this condition is called toddler's diarrhea.
- Environmental enteropathy
- Radiation enteropathy following treatment for pelvic and abdominal cancers.
Some medications, such as the penicillin can cause diarrhea. Over 700 medications are known to cause diarrhea. The classes of medications that are known to cause diarrhea are laxatives, antacids, heartburn medications, antibiotics, anti-neoplastic drugs, anti-inflammatories as well as many dietary supplements.
|Absorption||NHE, SGLT1, ENaC, DRA|
|Secretion||CaCC, NKCC1, CFTR|
|Absorption and secretion||Sodium potassium ATPase|
According to two researchers, Nesse and Williams, diarrhea may function as an evolved expulsion defense mechanism. As a result, if it is stopped, there might be a delay in recovery. They cite in support of this argument research published in 1973 that found that treating Shigella with the anti-diarrhea drug (Co-phenotrope, Lomotil) caused people to stay feverish twice as long as those not so treated. The researchers indeed themselves observed that: "Lomotil may be contraindicated in shigellosis. Diarrhea may represent a defense mechanism".
The following types of diarrhea may indicate further investigation is needed:
- In infants
- Moderate or severe diarrhea in young children
- Associated with blood
- Continues for more than two days
- Associated non-cramping abdominal pain, fever, weight loss, etc.
- In travelers
- In food handlers, because of the potential to infect others;
- In institutions such as hospitals, child care centers, or geriatric and convalescent homes.
A severity score is used to aid diagnosis in children.
When diarrhea lasts for more than four weeks a number of further tests may be recommended including:
- Complete blood count and a ferritin if anemia is present
- Thyroid stimulating hormone
- Tissue transglutaminase for celiac disease
- Fecal calprotectin to exclude inflammatory bowel disease
- Stool tests for ova and parasites as well as for Clostridioides difficile
- A colonoscopy or fecal immunochemical testing for cancer, including biopsies to detect microscopic colitis
- Testing for bile acid diarrhea with SeHCAT, 7α-hydroxy-4-cholesten-3-one or fecal bile acids depending on availability
- Hydrogen breath test looking for lactose intolerance
- Further tests if immunodeficiency, pelvic radiation disease or small intestinal bacterial overgrowth suspected.
A 2019 guideline recommended that testing for ova and parasites was only needed in people who are at high risk though they recommend routine testing for giardia. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were not recommended.
Numerous studies have shown that improvements in drinking water and sanitation (WASH) lead to decreased risks of diarrhoea. Such improvements might include for example use of water filters, provision of high-quality piped water and sewer connections.
In institutions, communities, and households, interventions that promote hand washing with soap lead to significant reductions in the incidence of diarrhea. The same applies to preventing open defecation at a community-wide level and providing access to improved sanitation. This includes use of toilets and implementation of the entire sanitation chain connected to the toilets (collection, transport, disposal or reuse of human excreta).
There is limited evidence that safe disposal of child or adult feces can prevent diarrheal disease.
Basic sanitation techniques can have a profound effect on the transmission of diarrheal disease. The implementation of hand washing using soap and water, for example, has been experimentally shown to reduce the incidence of disease by approximately 30–48%. Hand washing in developing countries, however, is compromised by poverty as acknowledged by the CDC: "Handwashing is integral to disease prevention in all parts of the world; however, access to soap and water is limited in a number of less developed countries. This lack of access is one of many challenges to proper hygiene in less developed countries." Solutions to this barrier require the implementation of educational programs that encourage sanitary behaviours.
Given that water contamination is a major means of transmitting diarrheal disease, efforts to provide clean water supply and improved sanitation have the potential to dramatically cut the rate of disease incidence. In fact, it has been proposed that we might expect an 88% reduction in child mortality resulting from diarrheal disease as a result of improved water sanitation and hygiene. Similarly, a meta-analysis of numerous studies on improving water supply and sanitation shows a 22–27% reduction in disease incidence, and a 21–30% reduction in mortality rate associated with diarrheal disease.
Chlorine treatment of water, for example, has been shown to reduce both the risk of diarrheal disease, and of contamination of stored water with diarrheal pathogens.
Immunization against the pathogens that cause diarrheal disease is a viable prevention strategy, however it does require targeting certain pathogens for vaccination. In the case of Rotavirus, which was responsible for around 6% of diarrheal episodes and 20% of diarrheal disease deaths in the children of developing countries, use of a Rotavirus vaccine in trials in 1985 yielded a slight (2–3%) decrease in total diarrheal disease incidence, while reducing overall mortality by 6–10%. Similarly, a Cholera vaccine showed a strong reduction in morbidity and mortality, though the overall impact of vaccination was minimal as Cholera is not one of the major causative pathogens of diarrheal disease. Since this time, more effective vaccines have been developed that have the potential to save many thousands of lives in developing nations, while reducing the overall cost of treatment, and the costs to society.
Rotavirus vaccine decreases the rates of diarrhea in a population. New vaccines against rotavirus, Shigella, Enterotoxigenic Escherichia coli (ETEC), and cholera are under development, as well as other causes of infectious diarrhea.
Dietary deficiencies in developing countries can be combated by promoting better eating practices. Zinc supplementation proved successful showing a significant decrease in the incidence of diarrheal disease compared to a control group. The majority of the literature suggests that vitamin A supplementation is advantageous in reducing disease incidence. Development of a supplementation strategy should take into consideration the fact that vitamin A supplementation was less effective in reducing diarrhea incidence when compared to vitamin A and zinc supplementation, and that the latter strategy was estimated to be significantly more cost effective.
Breastfeeding practices have been shown to have a dramatic effect on the incidence of diarrheal disease in poor populations. Studies across a number of developing nations have shown that those who receive exclusive breastfeeding during their first 6 months of life are better protected against infection with diarrheal diseases. One study in Brazil found that non-breastfed infants were 14 times more likely to die from diarrhea than exclusively breastfed infants. Exclusive breastfeeding is currently recommended for the first six months of an infant's life by the WHO, with continued breastfeeding until at least two years of age.
Probiotics decrease the risk of diarrhea in those taking antibiotics. Insecticide spraying may reduce fly numbers and the risk of diarrhea in children in a setting where there is seasonal variations in fly numbers throughout the year.
In many cases of diarrhea, replacing lost fluid and salts is the only treatment needed. This is usually by mouth – oral rehydration therapy – or, in severe cases, intravenously. Diet restrictions such as the BRAT diet are no longer recommended. Research does not support the limiting of milk to children as doing so has no effect on duration of diarrhea. To the contrary, WHO recommends that children with diarrhea continue to eat as sufficient nutrients are usually still absorbed to support continued growth and weight gain, and that continuing to eat also speeds up recovery of normal intestinal functioning. CDC recommends that children and adults with cholera also continue to eat. There is no evidence that early refeeding in children can cause an increase in inappropriate use of intravenous fluid, episodes of vomiting, and risk of having persistent diarrhea.
Medications such as loperamide (Imodium) and bismuth subsalicylate may be beneficial; however they may be contraindicated in certain situations.
Oral rehydration solution (ORS) (a slightly sweetened and salty water) can be used to prevent dehydration. Standard home solutions such as salted rice water, salted yogurt drinks, vegetable and chicken soups with salt can be given. Home solutions such as water in which cereal has been cooked, unsalted soup, green coconut water, weak tea (unsweetened), and unsweetened fresh fruit juices can have from half a teaspoon to full teaspoon of salt (from one-and-a-half to three grams) added per liter. Clean plain water can also be one of several fluids given. There are commercial solutions such as Pedialyte, and relief agencies such as UNICEF widely distribute packets of salts and sugar. A WHO publication for physicians recommends a homemade ORS consisting of one liter water with one teaspoon salt (3 grams) and two tablespoons sugar (18 grams) added (approximately the "taste of tears"). Rehydration Project recommends adding the same amount of sugar but only one-half a teaspoon of salt, stating that this more dilute approach is less risky with very little loss of effectiveness. Both agree that drinks with too much sugar or salt can make dehydration worse.
Appropriate amounts of supplemental zinc and potassium should be added if available. But the availability of these should not delay rehydration. As WHO points out, the most important thing is to begin preventing dehydration as early as possible. In another example of prompt ORS hopefully preventing dehydration, CDC recommends for the treatment of cholera continuing to give Oral Rehydration Solution during travel to medical treatment.
Vomiting often occurs during the first hour or two of treatment with ORS, especially if a child drinks the solution too quickly, but this seldom prevents successful rehydration since most of the fluid is still absorbed. WHO recommends that if a child vomits, to wait five or ten minutes and then start to give the solution again more slowly.
Drinks especially high in simple sugars, such as soft drinks and fruit juices, are not recommended in children under five as they may increase dehydration. A too rich solution in the gut draws water from the rest of the body, just as if the person were to drink sea water. Plain water may be used if more specific and effective ORT preparations are unavailable or are not palatable. Additionally, a mix of both plain water and drinks perhaps too rich in sugar and salt can alternatively be given to the same person, with the goal of providing a medium amount of sodium overall. A nasogastric tube can be used in young children to administer fluids if warranted.
The WHO recommends a child with diarrhea continue to be fed. Continued feeding speeds the recovery of normal intestinal function. In contrast, children whose food is restricted have diarrhea of longer duration and recover intestinal function more slowly. The WHO states "Food should never be withheld and the child's usual foods should not be diluted. Breastfeeding should always be continued." In the specific example of cholera, the CDC makes the same recommendation. Breast-fed infants with diarrhea often choose to breastfeed more, and should be encouraged to do so. In young children who are not breast-fed and live in the developed world, a lactose-free diet may be useful to speed recovery. Eating food containing fibers may help.
Antidiarrheal agents can be classified into four different groups: antimotility, antisecretory, adsorbent, and anti-infectious. While antibiotics are beneficial in certain types of acute diarrhea, they are usually not used except in specific situations. There are concerns that antibiotics may increase the risk of hemolytic uremic syndrome in people infected with Escherichia coli O157. In resource-poor countries, treatment with antibiotics may be beneficial. However, some bacteria are developing antibiotic resistance, particularly Shigella. Antibiotics can also cause diarrhea, and antibiotic-associated diarrhea is the most common adverse effect of treatment with general antibiotics.
While bismuth compounds (Pepto-Bismol) decreased the number of bowel movements in those with travelers' diarrhea, they do not decrease the length of illness. Anti-motility agents like loperamide are also effective at reducing the number of stools but not the duration of disease. These agents should be used only if bloody diarrhea is not present.
Diosmectite, a natural aluminomagnesium silicate clay, is effective in alleviating symptoms of acute diarrhea in children, and also has some effects in chronic functional diarrhea, radiation-induced diarrhea, and chemotherapy-induced diarrhea. Another absorbent agent used for the treatment of mild diarrhea is kaopectate.
Racecadotril an antisecretory medication may be used to treat diarrhea in children and adults. It has better tolerability than loperamide, as it causes less constipation and flatulence. However, it has little benefit in improving acute diarrhea in children.
Bile acid sequestrants such as cholestyramine can be effective in chronic diarrhea due to bile acid malabsorption. Therapeutic trials of these drugs are indicated in chronic diarrhea if bile acid malabsorption cannot be diagnosed with a specific test, such as SeHCAT retention.
Zinc supplementation may benefit children over six months old with diarrhea in areas with high rates of malnourishment or zinc deficiency. This supports the World Health Organization guidelines for zinc, but not in the very young.
A Cochrane Review from 2020 concludes that probiotics make little or no difference to people who have diarrhoea lasting 2 days or longer and that there is no proof that they reduce its duration. The probiotic lactobacillus can help prevent antibiotic-associated diarrhea in adults but possibly not children. For those with lactose intolerance, taking digestive enzymes containing lactase when consuming dairy products often improves symptoms.
Worldwide in 2004, approximately 2.5 billion cases of diarrhea occurred, which resulted in 1.5 million deaths among children under the age of five. Greater than half of these were in Africa and South Asia. This is down from a death rate of 4.5 million in 1980 for gastroenteritis. Diarrhea remains the second leading cause of infant mortality (16%) after pneumonia (17%) in this age group.
The majority of such cases occur in the developing world, with over half of the recorded cases of childhood diarrhea occurring in Africa and Asia, with 696 million and 1.2 billion cases, respectively, compared to only 480 million in the rest of the world.
Infectious diarrhea resulted in about 0.7 million deaths in children under five years old in 2011 and 250 million lost school days. In the Americas, diarrheal disease accounts for a total of 10% of deaths among children aged 1–59 months while in South East Asia, it accounts for 31.3% of deaths. It is estimated that around 21% of child mortalities in developing countries are due to diarrheal disease.
The word diarrhea is from the Ancient Greek διάρροια from διά dia "through" and ῥέω rheo "flow".
Diarrhea is the spelling in American English, whereas diarrhoea is the spelling in British English.
Slang terms for the condition include "the runs", "the squirts" (or "squits" in Britain) and "the trots".
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 "whqlibdoc.who.int". World Health Organization. http://whqlibdoc.who.int/publications/2009/9789241598415_eng.pdf.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 "Diarrhoeal disease Factsheet". 2 May 2017. https://www.who.int/en/news-room/fact-sheets/detail/diarrhoeal-disease.
- ↑ "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet 388 (10053): 1545–1602. October 2016. doi:10.1016/S0140-6736(16)31678-6. PMID 27733282.
- ↑ 4.0 4.1 "Diarrheal diseases". Our World in Data. 2018-11-01. https://ourworldindata.org/diarrheal-diseases.
- ↑ 5.0 5.1 5.2 Anesthesia for otolaryngologic surgery. Cambridge University Press. 2013. pp. 282–287. ISBN 978-1-107-01867-9.
- ↑ "Spectrum of gluten-related disorders: consensus on new nomenclature and classification". BMC Medicine 10: 13. February 2012. doi:10.1186/1741-7015-10-13. PMID 22313950.
- ↑ "Systematic review with meta-analysis: the prevalence of bile acid malabsorption in the irritable bowel syndrome with diarrhoea". Alimentary Pharmacology & Therapeutics 42 (1): 3–11. July 2015. doi:10.1111/apt.13227. PMID 25913530. http://eprints.whiterose.ac.uk/86190/3/MANUSCRIPT-REVISED%5B1%5D.pdf.
- ↑ 8.0 8.1 8.2 8.3 "Acute infectious diarrhea in immunocompetent adults". The New England Journal of Medicine 370 (16): 1532–40. April 2014. doi:10.1056/nejmra1301069. PMID 24738670.
- ↑ "Protection of Travelers". Principles and practice of pediatric infectious diseases (4th ed.). Edinburgh: Elsevier Saunders. 2012. p. 82. ISBN 978-1-4557-3985-1. https://books.google.com/books?id=TN2Gu2Af1BIC&pg=PA82.
- ↑ "Nation's Emergency Physicians Announce List of Test and Procedures to Question as Part of Choosing Wisely Campaign". 14 October 2013. http://www.choosingwisely.org/nations-emergency-physicians-announce-list-of-test-and-procedures-to-question-as-part-of-choosing-wisely-campaign/.
- ↑ "Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet 386 (9995): 743–800. August 2015. doi:10.1016/s0140-6736(15)60692-4. PMID 26063472.
- ↑ 12.0 12.1 "Global Diarrhea Burden". 24 January 2013. https://www.cdc.gov/healthywater/global/diarrhea-burden.html.
- ↑ "WGO Practice Guideline – Acute diarrhea". http://www.worldgastroenterology.org/acute-diarrhea-in-adults.html.
- ↑ "Cholera outbreak toobox". WHO. June 2019. https://www.who.int/docs/default-source/outbreak-toolkit/cholera-outbreak-data-collection-toolbox---layout-inis-27-june.pdf?sfvrsn=60036811_2.
- ↑ 15.0 15.1 15.2 "The Basics of Diarrhea". Webmd.com. 17 February 2011. http://www.webmd.com/digestive-disorders/digestive-diseases-diarrhea.
- ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 "Drug-induced secretory diarrhea: A role for CFTR". Pharmacological Research 102: 107–112. December 2015. doi:10.1016/j.phrs.2015.08.024. PMID 26429773.
- ↑ 17.00 17.01 17.02 17.03 17.04 17.05 17.06 17.07 17.08 17.09 17.10 "The Treatment Of Diarrhea, A manual for physicians and other senior health workers". World Health Organization. 2005. http://whqlibdoc.who.int/publications/2005/9241593180.pdf.
- ↑ "Evaluating the patient with diarrhea: a case-based approach". Mayo Clinic Proceedings 87 (6): 596–602. June 2012. doi:10.1016/j.mayocp.2012.02.015. PMID 22677080.
- ↑ 19.0 19.1 Disease Control Priorities Project. "Public Health Significance of Diarrheal Illnesses". The World Bank Group. http://www.dcp2.org/pubs/DCP/19/Section/2531.
- ↑ "Diarrhea as a cause and an effect of malnutrition: diarrhea prevents catch-up growth and malnutrition increases diarrhea frequency and duration". The American Journal of Tropical Medicine and Hygiene 47 (1 Pt 2): 28–35. July 1992. doi:10.4269/ajtmh.1992.47.28. PMID 1632474.
- ↑ "Nutritional deficiencies and later behavioural development". The Proceedings of the Nutrition Society 59 (1): 47–54. February 2000. doi:10.1017/S0029665100000069. PMID 10828173.
- ↑ Human Biology and Health. Englewood Cliffs, NJ: Prentice Hall. 1993. ISBN 978-0-13-981176-0. OCLC 32308337. https://archive.org/details/humanbiologyheal00scho.
- ↑ "Diarrhea: Types, Causes, Complications & Treatment". https://my.clevelandclinic.org/health/diseases/4108-diarrhea.
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- ↑ "Mechanisms of infectious diarrhea". Nature Clinical Practice. Gastroenterology & Hepatology 5 (11): 637–47. November 2008. doi:10.1038/ncpgasthep1264. PMID 18813221.
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- ↑ "Astrovirus gastroenteritis". The Pediatric Infectious Disease Journal 21 (11): 1067–9. November 2002. doi:10.1097/00006454-200211000-00018. PMID 12442031.
- ↑ Akhondi, Hossein; Simonsen, Kari A. (2022), "Bacterial Diarrhea", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 31869107, http://www.ncbi.nlm.nih.gov/books/NBK551643/, retrieved 2022-07-19
- ↑ "Enteric infection meets intestinal function: how bacterial pathogens cause diarrhoea". Nature Reviews. Microbiology 7 (2): 110–9. February 2009. doi:10.1038/nrmicro2053. PMID 19116615.
- ↑ "Clostridium difficile infection: new developments in epidemiology and pathogenesis". Nature Reviews. Microbiology 7 (7): 526–36. July 2009. doi:10.1038/nrmicro2164. PMID 19528959.
- ↑ "Nitazoxanide for the empiric treatment of pediatric infectious diarrhea". Transactions of the Royal Society of Tropical Medicine and Hygiene 106 (3): 167–73. March 2012. doi:10.1016/j.trstmh.2011.11.007. PMID 22301075.
- ↑ "Treatment of infectious diarrhea in children". Paediatric Drugs 5 (3): 151–65. 2003. doi:10.2165/00128072-200305030-00002. PMID 12608880.
- ↑ "WHO | Diarrhoeal disease". Who.int. https://www.who.int/mediacentre/factsheets/fs330/en/.
- ↑ Disease control priorities in developing countries (2nd ed.). New York: Oxford Univ. Press. 2006. ISBN 978-0-8213-6179-5.
- ↑ 39.0 39.1 "Water, sanitation, hygiene and enteric infections in children". Archives of Disease in Childhood 98 (8): 629–34. August 2013. doi:10.1136/archdischild-2011-301528. PMID 23761692.
- ↑ "Zinc and childhood infectious disease morbidity and mortality". The British Journal of Nutrition 85 Suppl 2: S125-9. May 2001. doi:10.1079/bjn2000304. PMID 11509100.
- ↑ "Zinc and immune function: the biological basis of altered resistance to infection". The American Journal of Clinical Nutrition 68 (2 Suppl): 447S–463S. August 1998. doi:10.1093/ajcn/68.2.447S. PMID 9701160.
- ↑ "Plasma zinc as a predictor of diarrheal and respiratory morbidity in children in an urban slum setting". The American Journal of Clinical Nutrition 68 (2 Suppl): 414S–417S. August 1998. doi:10.1093/ajcn/68.2.414S. PMID 9701154.
- ↑ "Vitamin A deficiency". Comparative quantification of health risks: global and regional burden of disease attributes to selected major risk factors.. 1. Geneva: World Health Organization. 2004. pp. 211–56, especially 238–240. http://apps.who.int/iris/bitstream/handle/10665/42792/9241580348_eng_Volume1.pdf.
- ↑ "Increased risk of respiratory disease and diarrhea in children with preexisting mild vitamin A deficiency". The American Journal of Clinical Nutrition 40 (5): 1090–5. November 1984. doi:10.1093/ajcn/40.5.1090. PMID 6496388.
- ↑ "Extent of vitamin A deficiency among preschool children and women of reproductive age". The Journal of Nutrition 132 (9 Suppl): 2857S–2866S. September 2002. doi:10.1093/jn/132.9.2857S. PMID 12221262.
- ↑ "Functional bowel disorders". Gastroenterology 130 (5): 1480–91. April 2006. doi:10.1053/j.gastro.2005.11.061. PMID 16678561.
- ↑ "Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome". Alimentary Pharmacology & Therapeutics 30 (7): 707–17. October 2009. doi:10.1111/j.1365-2036.2009.04081.x. PMID 19570102.
- ↑ Harrison's Principles of Internal Medicine. New York: McGraw-Hill. 2005. ISBN 978-0-07-139140-5.
- ↑ 49.0 49.1 49.2 49.3 "Pharmacologic Agents for Chronic Diarrhea". Intestinal Research 13 (4): 306–12. October 2015. doi:10.5217/ir.2015.13.4.306. PMID 26576135.
- ↑ Davis's drug guide for nurses. Philadelphia: F.A. Davis Company. 2017. pp. 989–994. ISBN 978-0-8036-5705-2.
- ↑ "Diarrhea & Incontinence Caused by Medication". International Foundation for Gastrointestinal Disorders (IFFGD). https://www.iffgd.org/lower-gi-disorders/diarrhea/diarrhea-incontinence-caused-by-medication.html.
- ↑ "The Role of Ion Transporters in the Pathophysiology of Infectious Diarrhea". Cellular and Molecular Gastroenterology and Hepatology 6 (1): 33–45. 2018. doi:10.1016/j.jcmgh.2018.02.009. PMID 29928670.
- ↑ Why we get sick: the new science of Darwinian medicine. New York: Vintage Books. 1996. pp. 36–38. ISBN 978-0-679-74674-4.
- ↑ "Adverse effect of lomotil therapy in shigellosis". JAMA 226 (13): 1525–8. December 1973. doi:10.1001/jama.226.13.1525. PMID 4587313.
- ↑ "Rotavirus disease in Finnish children: use of numerical scores for clinical severity of diarrhoeal episodes". Scandinavian Journal of Infectious Diseases 22 (3): 259–67. 1990. doi:10.3109/00365549009027046. PMID 2371542.
- ↑ "Guidelines for the investigation of chronic diarrhoea in adults: British Society of Gastroenterology, 3rd edition". Gut 67 (8): 1380–1399. August 2018. doi:10.1136/gutjnl-2017-315909. PMID 29653941.
- ↑ 57.0 57.1 "AGA Clinical Practice Guidelines on the Laboratory Evaluation of Functional Diarrhea and Diarrhea-Predominant Irritable Bowel Syndrome in Adults (IBS-D)". Gastroenterology 157 (3): 851–854. September 2019. doi:10.1053/j.gastro.2019.07.004. PMID 31302098.
- ↑ 58.0 58.1 "Assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression". Tropical Medicine & International Health 19 (8): 928–42. August 2014. doi:10.1111/tmi.12331. PMID 24811732. https://ueaeprints.uea.ac.uk/51912/1/Wolf_2014_Assessing_impact_of_drinking_water.pdf.
- ↑ 59.0 59.1 "Hand-washing promotion for preventing diarrhoea". The Cochrane Database of Systematic Reviews 12 (1): CD004265. January 2021. doi:10.1002/14651858.CD004265.pub4. PMID 33539552.
- ↑ 60.0 60.1 "Call to action on sanitation". http://sanitationdrive2015.org/wp-content/uploads/2013/03/DSG_Sanitation_Fast-Facts_final.pdf.
- ↑ "Open defecation and childhood stunting in India: an ecological analysis of new data from 112 districts". PLOS ONE 8 (9): e73784. 2013. doi:10.1371/journal.pone.0073784. PMID 24066070. Bibcode: 2013PLoSO...873784S.
- ↑ "Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection". The Cochrane Database of Systematic Reviews 9 (9): CD011055. September 2019. doi:10.1002/14651858.CD011055.pub2. PMID 31549742.
- ↑ "Interventions to improve disposal of human excreta for preventing diarrhoea". The Cochrane Database of Systematic Reviews 2010 (6): CD007180. June 2010. doi:10.1002/14651858.CD007180.pub2. PMID 20556776.
- ↑ "Effect of washing hands with soap on diarrhoea risk in the community: a systematic review". The Lancet. Infectious Diseases 3 (5): 275–81. May 2003. doi:10.1016/S1473-3099(03)00606-6. PMID 12726975.
- ↑ "Water, sanitation and hygiene for the prevention of diarrhoea". International Journal of Epidemiology 39 Suppl 1 (Suppl 1): i193-205. April 2010. doi:10.1093/ije/dyq035. PMID 20348121.
- ↑ "Diarrheal Diseases in Less Developed Countries". CDC. https://www.cdc.gov/healthywater/hygiene/ldc/diarrheal_diseases.html.
- ↑ "Where and why are 10 million children dying every year?". Lancet 361 (9376): 2226–34. June 2003. doi:10.1016/S0140-6736(03)13779-8. PMID 12842379.
- ↑ "Interventions for the control of diarrhoeal diseases among young children: improving water supplies and excreta disposal facilities". Bulletin of the World Health Organization 63 (4): 757–72. 1985. PMID 3878742.
- ↑ "Treating water with chlorine at point-of-use to improve water quality and reduce child diarrhea in developing countries: a systematic review and meta-analysis". The American Journal of Tropical Medicine and Hygiene 76 (2): 354–64. February 2007. doi:10.4269/ajtmh.2007.76.354. PMID 17297049.
- ↑ "Interventions for the control of diarrhoeal diseases among young children: rotavirus and cholera immunization". Bulletin of the World Health Organization 63 (3): 569–83. 1985. PMID 3876173.
- ↑ "Economic costs of rotavirus gastroenteritis and cost-effectiveness of vaccination in developing countries". The Journal of Infectious Diseases 200 Suppl 1: S16-27. November 2009. doi:10.1086/605026. PMID 19817595.
- ↑ Oral cholera vaccines in mass immunization campaigns. WHO. 2010. pp. 6–8. ISBN 978-92-4-150043-2. http://whqlibdoc.who.int/publications/2010/9789241500432_eng.pdf.
- ↑ "Rotavirus vaccine for preventing diarrhoea". The Cochrane Database of Systematic Reviews 2004 (1): CD002848. 2004-01-26. doi:10.1002/14651858.CD002848.pub2. PMID 14973994.
- ↑ "Zinc deficiency, infectious disease and mortality in the developing world". The Journal of Nutrition 133 (5 Suppl 1): 1485S–9S. May 2003. doi:10.1093/jn/133.5.1485S. PMID 12730449.
- ↑ "Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries: pooled analysis of randomized controlled trials. Zinc Investigators' Collaborative Group". The Journal of Pediatrics 135 (6): 689–97. December 1999. doi:10.1016/S0022-3476(99)70086-7. PMID 10586170.
- ↑ "Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis". BMJ 343: d5094. August 2011. doi:10.1136/bmj.d5094. PMID 21868478.
- ↑ "Cost of childhood diarrhoea in rural South Africa: exploring cost-effectiveness of universal zinc supplementation". Public Health Nutrition 17 (9): 2138–45. September 2014. doi:10.1017/S1368980013002152. PMID 23930984.
- ↑ "Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis. WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality". Lancet 355 (9202): 451–5. February 2000. doi:10.1016/S0140-6736(00)82011-5. PMID 10841125.
- ↑ Breastfeeding : a guide for the medical profession, 8th edition. Philadelphia, PA: Elsevier. 2016. p. 28. ISBN 978-0-323-35776-0.
- ↑ "Optimal duration of exclusive breastfeeding: RHL commentary". WHO. http://apps.who.int/rhl/pregnancy_childbirth/care_after_childbirth/yscom/en/.
- ↑ 81.0 81.1 "Infant and young child feeding". 3 October 2017. https://www.who.int/mediacentre/factsheets/fs342/en/.
- ↑ "Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis". JAMA: The Journal of the American Medical Association 307 (18): 1959–69. May 2012. doi:10.1001/jama.2012.3507. PMID 22570464.
- ↑ "Fly control to prevent diarrhoea in children". The Cochrane Database of Systematic Reviews 12 (12): CD011654. December 2018. doi:10.1002/14651858.CD011654.pub2. PMID 30556598.
- ↑ "Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy". MMWR. Recommendations and Reports 52 (RR-16): 1–16. November 2003. PMID 14627948. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5216a1.htm.
- ↑ "BestBets: Does Withholding milk feeds reduce the duration of diarrhoea in children with acute gastroenteritis?". http://www.bestbets.org/bets/bet.php?id=1728.
- ↑ 86.0 86.1 86.2 Community Health Worker Training Materials for Cholera Prevention and Control , CDC, slides at back are dated 17 November 2010. Page 7 states "... Continue to breastfeed your baby if the baby has watery diarrhea, even when traveling to get treatment. Adults and older children should continue to eat frequently."
- ↑ "Early versus Delayed Refeeding for Children with Acute Diarrhoea". The Cochrane Database of Systematic Reviews 2011 (7): CD007296. July 2011. doi:10.1002/14651858.CD007296.pub2. PMID 21735409.
- ↑ "Management of diarrhea in clinical practice: strategies for primary care physicians". Reviews in Gastroenterological Disorders 7 Suppl 3 (Suppl 3): S27-38. 2007. PMID 18192963.
- ↑ A Guide on Safe Food for Travellers , Welcome to South Africa, Host to the 2010 FIFA World Cup (bottom left of page 1).
- ↑ 90.0 90.1 Rehydration Project, "Diarrhoea, Diarrhea, Dehydration, Oral Rehydration, Mother and Child Nutrition, Water, Sanitation, Hygiene – Rehydration Project". http://rehydrate.org/. Homemade Oral Rehydration Solution Recipe.
- ↑ 91.0 91.1 "Management of acute diarrhoea and vomiting due to gastroenteritis in children under 5". National Institute of Clinical Excellence. April 2009. http://guidance.nice.org.uk/CG84.
- ↑ "Acute gastroenteritis in children". Australian Family Physician 34 (4): 227–31. April 2005. PMID 15861741.
- ↑ "Lactose avoidance for young children with acute diarrhoea". The Cochrane Database of Systematic Reviews 10 (10): CD005433. October 2013. doi:10.1002/14651858.CD005433.pub2. PMID 24173771.
- ↑ "The Facts About Fiber". https://www.webmd.com/digestive-disorders/chronic-diarrhea-16/diarrhea-more-fiber.
- ↑ 95.0 95.1 "Clinical role of diosmectite in the management of diarrhea.". Expert Opin Drug Metab Toxicol 5 (4): 433–440. 2009. doi:10.1517/17425250902865594. PMID 19379128.
- ↑ "Empirical treatment of severe acute community-acquired gastroenteritis with ciprofloxacin". Clinical Infectious Diseases 22 (6): 1019–25. June 1996. doi:10.1093/clinids/22.6.1019. PMID 8783703.
- ↑ 97.0 97.1 "Diarrhoea in adults (acute)". BMJ Clinical Evidence 2008: 0901. March 2008. PMID 19450323.
- ↑ "The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections". The New England Journal of Medicine 342 (26): 1930–6. June 2000. doi:10.1056/NEJM200006293422601. PMID 10874060.
- ↑ "Diarrhoeal Diseases". World Health Organization. February 2009. https://www.who.int/vaccine_research/diseases/diarrhoeal/en/index6.html.
- ↑ "Expert review of the evidence base for self-therapy of travelers' diarrhea". Journal of Travel Medicine 16 (3): 161–71. 2009. doi:10.1111/j.1708-8305.2009.00300.x. PMID 19538576.
- ↑ "Diagnosis and treatment of acute or persistent diarrhea". Gastroenterology 136 (6): 1874–86. May 2009. doi:10.1053/j.gastro.2009.02.072. PMID 19457416.
- ↑ "Anti-diarrheal effects of diosmectite in the treatment of acute diarrhea in children: a review". Paediatric Drugs 11 (2): 89–99. 2009. doi:10.2165/00148581-200911020-00001. PMID 19301931.
- ↑ (in de) Arzneistoff-Profile. Eschborn, Germany: Govi Pharmazeutischer Verlag. 1982. ISBN 978-3-7741-9846-3.
- ↑ "Racecadotril for acute diarrhoea in children". The Cochrane Database of Systematic Reviews 12 (12): CD009359. December 2019. doi:10.1002/14651858.CD009359.pub2. PMID 31858591.
- ↑ "Systematic review: the management of chronic diarrhoea due to bile acid malabsorption". Alimentary Pharmacology & Therapeutics 39 (9): 923–39. May 2014. doi:10.1111/apt.12684. PMID 24602022.
- ↑ "Oral zinc for treating diarrhoea in children". The Cochrane Database of Systematic Reviews 12 (12): CD005436. December 2016. doi:10.1002/14651858.CD005436.pub5. PMID 27996088.
- ↑ "Probiotics for treating acute infectious diarrhoea". The Cochrane Database of Systematic Reviews 2020 (12): CD003048. December 2020. doi:10.1002/14651858.CD003048.pub4. PMID 33295643.
- ↑ "Role of Lactobacillus in the prevention of antibiotic-associated diarrhea: a meta-analysis". Pharmacotherapy 30 (2): 119–26. February 2010. doi:10.1592/phco.30.2.119. PMID 20099986.
- ↑ "Mortality and Burden of Disease Estimates for WHO Member States in 2004" (xls). World Health Organization. https://www.who.int/entity/healthinfo/global_burden_disease/gbddeathdalycountryestimates2004.xls.
- ↑ Mandell's Principles and Practices of Infection Diseases (6th ed.). Churchill Livingstone. 2004. ISBN 978-0-443-06643-6. http://www.ppidonline.com/.
- ↑ "Diarrhoea: why children are still dying and what can be done". World Health Organization. http://whqlibdoc.who.int/publications/2009/9789241598415_eng.pdf.
- ↑ "Global burden of childhood pneumonia and diarrhoea". Lancet 381 (9875): 1405–1416. April 2013. doi:10.1016/S0140-6736(13)60222-6. PMID 23582727.
- ↑ "Estimating diarrhea mortality among young children in low and middle income countries". PLOS ONE 7 (1): e29151. 2012. doi:10.1371/journal.pone.0029151. PMID 22235266. Bibcode: 2012PLoSO...729151F.
- ↑ "The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000". Bulletin of the World Health Organization 81 (3): 197–204. 2003. PMID 12764516.
- ↑ The dictionary definition of squits at Wiktionary
- ↑ The dictionary definition of runs at Wiktionary
- ↑ "Definition of Diarrhea by Merriam-Webster". Definition of Diarrhea by Merriam-Webster. https://www.merriam-webster.com/dictionary/diarrhea#synonyms. Retrieved 11 December 2018.
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